Abstract
The 10th Annual National Conference on Fetal Monitoring was held on 2–4 April, 2009, in Las Vegas (NV, USA). Registrants included physicians, midwives, nurses and risk managers interested in the latest updates and innovations in electronic fetal monitoring. The program was coordinated by Symposia Medicus, with co-chairs David A Miller and Lisa A Miller. The focus of this year’s program was on maternal–fetal assessments and interventions, and included a variety of contemporary and clinically important topics.
The program began with general sessions by the co-chairs focusing on the National Institute of Child Health and Human Development terminology, as well as the adoption of a standardized interpretation and management approach to intrapartum fetal heart rate (FHR) monitoring. Using an audience-response system, participants were able to anonymously answer questions regarding common National Institute of Child Health and Human Development terminology, FHR physiology and widespread beliefs regarding electronic fetal monitoring. Central concepts related to evidence-based FHR interpretation were reviewed, and an algorithm for intrapartum management of the FHR tracing was outlined by David Miller (CHLA-USC Institute for Maternal and Fetal Health, CA, USA). Principles of fetal oxygenation and fetal response to disrupted oxygenation were reviewed, as well as factors unrelated to hypoxemia that can result in FHR changes. This was the basis for three standardized interpretation concepts:
• All clinically significant FHR decelerations reflect disruption of oxygenation to some degree;
• Disrupted oxygenation intrapartally will not cause injury unless it first progresses to the level of metabolic acidemia;
• Fetal metabolic acidemia can be reliably excluded if the FHR tracing has either moderate variability or acceleration.
These central concepts provide the basis for the standardized management algorithm, which consists of a series of assessments to determine whether management should be routine surveillance, heightened surveillance or operative delivery. The algorithm includes evaluation of uterine activity, as well as the five components of FHR, evaluation of fetal acid–base status and clinical decision-making based on the likelihood of the development of fetal metabolic acidemia versus the time to vaginal delivery. The management model was also discussed, as it relates to the legal standard of care, and D Miller stressed the importance of showing a clear plan to meet the standards of reasonableness and prudence common in the majority of jurisdictions in the USA.
Petra CAM Bakker (Vrije Universiteit Medical Center, Amsterdam, The Netherlands) presented her research on the relationship of uterine activity and fetal acid–base status, which shows a direct and dramatic correlation between excessive uterine activity and an increase in fetal acidemia at birth. Bakker emphasized the importance of relaxation time in relation to fetal oxygenation and linked increased frequency of uterine contractions to a greater risk of decreased pH at birth. Parameters for adequate versus excessive uterine activity were reviewed, and clinicians were urged to be vigilant in assessing uterine activity accurately and rigorously. The combination of focus on standardized interpretation and management of intrapartum FHR with renewed vigor in the appreciation of the relationship of uterine activity to fetal acid–base status provided attendees with the basis for an evidence-based approach to intrapartum FHR management that can be utilized by the entire obstetric team as part of an overall safety focus.
Liability issues were presented by two members of the plaintiff’s bar, James Kelley and Stephen Crandall (Elk & Elk, OH, USA). This session produced a lively and provocative discussion from the audience related to defensibility issues. Documentation and disclosure practices were two of the key areas for improvement cited by the attorneys. Citing patient and family interviews, the attorneys pointed out the most common complaint from clients seeking to file suit is the feeling that the healthcare team did not fully explain what had happened, and the common belief that information was being kept from them after a poor outcome. This is consistent with disclosure literature and the importance of simply taking the time to see the family and discuss the events and situation surrounding the birth cannot be overstated. Clinicians were exhorted to learn and apply appropriate disclosure practices when faced with an unexpected outcome or sentinel event. Documentation problems were also addressed, the most common being a simple lack of documentation showing a clear plan and the problems related to defensibility when there is conflict in the medical record between nursing and medical documentation. Strategies for improving both documentation and communication between disciplines were emphasized, and participants had the opportunity to share their views on liability issues during the forum.
Patricia Witcher (Northside Hospital, GA, US) provided a review of the evidence related to techniques of intrauterine resuscitation, including a critique of the use of oxygen as a first-line response. Following an in-depth review of fetal oxygenation, including fetal defense mechanisms that provide protection from the effects of interrupted oxygenation during labor, Witcher discussed in detail the evidence for conventional intrauterine resuscitation techniques, including maternal positioning, intravenous fluid bolus and reduction of uterine activity. Two topics of note were the importance of oxytocin titration in managing uterine activity and the current rethinking of a common nursing practice, supplemental oxygen as a first-line response during intrauterine resuscitation. Witcher followed with the appropriate use of scalp stimulation to rule out fetal acidemia and a reminder to clinicians to avoid its use during a deceleration or bradycardia. Amnioinfusion was also reviewed and, although no longer recommended for meconium-stained amniotic fluid, it remains in use for the management of variable decelerations of the FHR. Witcher shared a number of FHR case studies in both antepartum and intrapartum settings, including cases from high-risk settings, allowing attendees to learn from common clinical errors in FHR management.
An overview of different factors affecting FHR and unique issues in fetal monitoring of twins was presented by Bakker. Pointing out the significant risk to the second twin due to frequent difficulties with monitoring, she presented several dramatic case study examples of signal loss, as well as pickup of maternal heart rate being mistaken for the heart rate of the second twin. Bakker concluded with several management recommendations, including dedicated nursing staff with experience in monitoring, consideration of internal monitoring of the first twin should fetal signal-loss occurs, use of continous maternal heart-rate monitoring, verification by ultrasound of the FHR of the second twin following the birth of the first, and consideration of internal monitoring for the second twin if undelivered within 15 min. General sessions also consisted of a detailed discussion of documentation issues, including electronic documentation, presented by Lisa Miller (Perinatal Risk Management & Education Services, IL, USA); a review of antepartum testing techniques by D Miller; and a clinical update on second-stage management from Witcher.
In addition to the general sessions, participants were able to attend specialty workshops. D Miller provided a workshop on common fetal monitoring myths and misconceptions, debunking many long-held beliefs and revealing just how limited the evidence is for many common clinical concepts in the literature. Bakker and D Miller discussed the significant differences in terminology between European countries and the USA, as well as variations in clinical practice. L Miller introduced a number of participants to the latest adjunct to electronic fetal monitoring in the USA, ST analysis of the FHR. This technology is being widely used outside of the USA, and workshop attendees were able to review real-time cases using a special viewer from Neoventa (IL, USA), the makers of ST analysis. Use of ST analysis as an adjunct to standardized interpretation and management was demonstrated, and participants were asked to analyze FHR tracings and predict newborn umbilical cord gases both with and without ST data evaluation.
The 11th Annual National Conference on Fetal Monitoring is scheduled for 22–24 April, 2010, in Las Vegas (NV, USA).
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.